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Slide 1 - Sexually Transmitted Infections Unit 15 HIV Care and ART: A Course for Physicians
Slide 2 - 2 Learning Objectives Differentiate STI and STD Describe the epidemiology of STIs Describe syndromic management of STIs Illustrate: The impact of STI on HIV The impact of HIV on STI Demonstrate the importance of HIV testing and counseling in patients with STIs
Slide 3 - 3 STI versus STD STI – Infections acquired through sexual intercourse (may be symptomatic or asymptomatic) STD – Symptomatic disease acquired through sexual intercourse STI is most commonly used because it applies to both symptomatic and asymptomatic infections
Slide 4 - 4 Estimated New Cases of Curable* STIs Among Adults
Slide 5 - 5 Prevalence and Incidence of STIs Higher among urban residents, unmarried, and young adults Differs between countries and regions within countries Differences can be caused by social, cultural, and economic factors, or levels of access to care
Slide 6 - 6 STIs in Ethiopia No uniformity in reporting STI cases Only surveillance system is for HIV and syphilis among pregnant women All regions (except SNNPR) reported 451,686 cases of STIs between June 1998 and June 2002 This number reflects severe underreporting
Slide 7 - 7 STI Dissemination The rate of STI dissemination depends upon: Rate of exposure Efficiency of transmission per exposure Duration of infectiousness STI dissemination can be reduced by: Behavior modification: limiting partners, condom use Screening of risk groups, pregnant women, and their partners Treating all infections Health education and risk reduction counseling Partner notification
Slide 8 - 8 Challenges to Prevention Difficult to change human behavior Co-infection with multiple STIs is common Not all STIs are treatable Many STIs are asymptomatic Transmission can occur during asymptomatic viral shedding
Slide 9 - 9 How Symptomatic are STIs? Source: WHO HIV/AIDS/STI Initiative
Slide 10 - 10 Impact of STIs Considerable morbidity High rate of complications Facilitate HIV transmission and acquisition May cause infertility Treatment can be a high financial burden May cause problems in relationships—divorce, abandonment, beatings
Slide 11 - 11 Interaction Between HIV and STIs Significant interaction exists between HIV and STIs Affect similar populations Have a similar route of transmission The interaction is bidirectional HIV influences conventional STIs STIs influence HIV
Slide 12 - 12 Influence of HIV Infection on STIs HIV alters the clinical features of STIs Syphilis: Neurosyphilis develops more frequently and rapidly HSV: Ulcers are more severe, chronic, and possibly disseminate throughout body Response to treatment may be reduced High rates of treatment failure for neurosyphilis Complications may increase and occur more quickly
Slide 13 - 13 Influence of STI on HIV infection Increased transmission of HIV A person with STI has greater chance of transmitting and acquiring HIV infection Implications of the interaction: Reduction in conventional STI could result in reduction of HIV incidence Effective STI prevention and control should be components of HIV prevention programs
Slide 14 - STI Management
Slide 15 - 15 Syndromic Approach to STI Management Identification of clinical syndrome Giving treatment targeting all the locally known pathogens which can cause the syndrome
Slide 16 - 16 Syndromic Approach to STI Management (2) Advantages Simple, rapid and inexpensive Complete care offered at first visit Patients are treated for possible mixed infections Accessible to a broad range of health workers Avoids unnecessary referrals to hospitals Disadvantages Over-treatment Asymptomatic infections are missed
Slide 17 - 17 Examination of the STI Patient Physical examination should include: Examination of anogenital area Examination of any other symptomatic areas, e.g., skin, joints, neurological, etc. Additional examinations in females Speculum examination Bimanual pelvic examination
Slide 18 - 18 History of the STI Patient Presenting symptoms Previous diagnosis of STI Sexual history Symptoms and diagnosis in sexual partner Past general medical history Current medications Risk factors for the acquisition of HIV and STIs In females: obstetric, menstrual history, and use of contraceptives
Slide 19 - 19 Talking about STIs with Patients Important to understand the patient’s perspective on talking about sex Embarrassed Nervous Guilty Shame, fear Patients would like their medical provider to be Nonjudgmental Respectful Maintain privacy and confidentiality
Slide 20 - 20 Group Discussion: Patient-centered vs. Provider-centered Approach to Care What are the key differences between the patient- and provider-centered approaches to care? What are the positive and negative aspects of each approach? How would these different approaches possibly impact patient outcomes?
Slide 21 - 21 Principles of Patient-Centered Care Communicate in a nonjudgmental manner Explore the disease and the patient’s feelings and perceptions about their condition Understand the patient as a whole person Come to a mutual understanding with the patient regarding disease management
Slide 22 - 22 Building Rapport Begin with a non-medical interaction Create an atmosphere that is open and supportive Practice “active listening” Discuss a detailed agenda of what will occur Answer questions using simple terms the patient can understand
Slide 23 - 23 Expert Communication Skills Maintain good eye contact Use active listening and watch the patient’s nonverbal cues Have warm and accepting body language Rely on open ended questions Avoid interrupting Use summaries and reflections
Slide 24 - STI Syndromes and Management
Slide 25 - 25 Common STI Syndromes Urethral discharge or burning on urination in men Vaginal discharge Genital ulcer in men and women Lower abdominal pain in women Scrotal swelling Inguinal bubo
Slide 26 - 26 Case Study: Tsegenet Tsegenet is a 48 year-old woman who presents with a new genital lesion noted 4 days ago by her sex partner. The lesions is essentially asymptomatic except occasional mild pruritus. She reports a new male sex partner starting 2 months ago.
Slide 27 - 27 Case Study: Tsegenet (2)
Slide 28 - 28 Case Study: Tsegenet (3) What additional information do you wish to know about this patient? Based on the history you have and the appearance of the lesion, what does your differential diagnosis include?
Slide 29 - 29 Genital Ulcer Syndrome
Slide 30 - 30 Genital Ulcer Disease: Differential Diagnosis Herpes simplex Syphilis Chancroid Lymphogranuloma venereum Granuloma inguinale Others
Slide 31 - 31 Differential Diagnosis? Courtesy of the Division of STD Prevention/CDC
Slide 32 - 32 Differential Diagnosis? Courtesy of the Division of STD Prevention/CDC
Slide 33 - 33 Differential Diagnosis? Courtesy of the Cincinnati STD/ HIV Prevention Training Center
Slide 34 - 34 Differential Diagnosis?
Slide 35 - 35 Differential Diagnosis? Courtesy of Peter Katsufrakis, MD
Slide 36 - 36 Differential Diagnosis? Courtesy of Peter Katsufrakis, MD
Slide 37 - 37 Differential Diagnosis? Courtesy of the Public Health Image Library/CDC
Slide 38 - 38 Differential Diagnosis? Courtesy of the Public Health Image Library/CDC
Slide 39 - 39 Genital Ulcer Disease Treatment Recommended treatment for non-vesicular genital ulcer Benzanthine penicilline 2.4 million units IM stat or Doxycycline 100 mg bid for 15 days and Ciprofloxacin 500mg, po, bid for 3 days, or Erythromycin 500 mg, po, QID for 7 days Recommended treatment for vesicular or recurrent genital ulcer Acyclovir 200 mg five times per day for 10 days, or Acyclovir 400 mg TID for 10 days
Slide 40 - 40 Herpes Viruses 8 human herpesviruses (HHVs) α-herpesviruses include : Herpes simplex virus (HSV)-1 Herpes simplex virus (HSV)-2 Varicella zoster virus β-herpesviruses include: Epstein-Barr virus Kaposi’s sarcoma-associated herpes virus (KSHV or HHV-8)
Slide 41 - 41 HSV Spectrum of Disease Persistent ulcerative HSV infections are very common in AIDS Candida and HSV often occur in association Oral-facial Primary: gingivostomatitis & pharyngitis Reactivation: herpes labialis Asymptomatic shedding is common Thus, patients are potentially infectious even when lesions are absent
Slide 42 - 42 HSV Spectrum of Disease: Primary genital infection Fever, malaise, myalgia, HA, pain, itching, dysuria, vaginal and urethral discharge Tender inguinal adenopathy, widely-spaced bilateral extra-genital lesions Cervix and urethra involved in 80% of women If a pregnant woman has active lesions, C-section is indicated to prevent herpes neonatorum in infant Occasionally: endometritis, proctitis & prostatitis Extensive perianal disease, proctitis, or both are common among HIV patients
Slide 43 - 43 Extensive Herpes Simplex Ulcers Courtesy of HIV In Site,
Slide 44 - 44 HSV in the Immunocompromised Host High frequency of reactivation Increased severity Widespread local extension Higher incidence of dissemination Viremic spread to visceral organs, which is rare but can be life threatening
Slide 45 - 45 HSV Epidemiology By age 50, >90% people have HSV-1 antibodies Prevalence correlates with socioeconomic status HSV-2 appears at puberty and correlates with sexual activity Average world prevalence is about 25%
Slide 46 - 46 HSV vesicles Courtesy of CDC/ Susan Lindsley
Slide 47 - 47 HSV circumferential ulcer Courtesy of CDC/ Dr. M. F. Rein; Susan Lindsley
Slide 48 - 48 HSV Diagnosis Clinical – characteristic multiple vesicular lesions or ulcers Staining of scrapings from base of lesions to demonstrate characteristic giant cells or intranuclear inclusions Wright stain Tzanck preparation Papanicolaou smear
Slide 49 - 49 Treatment Primary infection Acyclovir 200 mg PO 5x/day for 7-14 days, or Acyclovir 400mg PO tid for 7-14 days, or Famciclovir 500 mg PO bid for 7-14 days, or Valacyclovir 1 gm PO bid 7-14 days Recurrences treated with same dosage, but may need only 5-10 days therapy Suppressive therapy may be indicated for patients with frequent recurrences, BUT Continued treatment risks developing resistant HSV
Slide 50 - 50 Case Study: Abel Abel is a 26 year-old man who presents with tingling that has progressed to frank burning with urination, beginning 3 days ago. He also reports copious purulent urethral discharge. When asked, he admits to unprotected intercourse last weekend with a new partner.
Slide 51 - 51 Case Study: Abel (2) Courtesy of Peter Katsufrakis, MD
Slide 52 - 52 Case Study: Abel (3) What additional information do you wish to know about this patient? Based on the history you have and the appearance of the lesion, what does your differential diagnosis include? If the patient instead appeared as on the following slide, how would this affect your differential diagnosis and management?
Slide 53 - 53 Case Study: Abel (4) Courtesy of Peter Katsufrakis, MD
Slide 54 - 54 Differential Diagnosis Chlamydia Gonorrhea Mycoplasma hominis Ureaplasma urealyticum Hemophilus & Parahemophilus spp. Other bacteria
Slide 55 - 55 Urethral Discharge Syndrome
Slide 56 - 56 Recommended Treatment for Urethral Discharge and Burning on Urination Ciprofloxacin 500 mg po stat, or Spectinomycin 2g IM stat Plus Doxycycline 100 mg po BID for 7 days, or Tetracycline 500 mg po QID for 7 days, or Erythromycin 500 mg po QID for 7 days if the patient has contraindications for Tetracyclines
Slide 57 - Persistent or Recurrent Urethral Discharge in Men
Slide 58 - 58 Case Study: Aida Aida, a 34 year-old woman, presents with a 2 month history of increasing, painless lesions she calls “hemorrhoids”. She also notes frequent, minimal bright red blood following bowel movements, and complains of perianal itching, and feeling “wet”.
Slide 59 - 59 Case Study: Aida (2) Courtesy of Peter Katsufrakis, MD
Slide 60 - 60 Condyloma accuminata Courtesy of Peter Katsufrakis, MD
Slide 61 - 61 Condyloma accuminata Courtesy of Peter Katsufrakis, MD
Slide 62 - 62 Chlamydial Cervicitis Courtesy of STD/HIV Prevention Training Center at the University of Washington/ Connie Celum and Walter Stamm
Slide 63 - 63 Genital Wart Treatments Internal Bi- or tri-chloroacetic acid Cryotherapy Cautery Laser or other surgery External Podophyllin Imiquimod Bi- or tri-chloroacetic acid Cryotherapy Cautery Laser or other surgery
Slide 64 - 64 Case Study: Redeit Redeit is a 26 year-old woman in a steady relationship with her boyfriend of 1 year. She presents complaining of a vaginal discharge for the past week. She describes increased discharge, change in color, and a foul odor.
Slide 65 - 65 Case Study: Redeit (cont.) Is this a sexually transmitted infection? What are the likely causative organisms?
Slide 66 - 66 Vaginal Discharge Common causes: Neisseria gonorrhea Chlamydia trachomatis Trichomonas vaginalis Gardnerella vaginalis Candida albicans
Slide 67 - 67 Patient complains of vaginal discharge or vulval itching/ burning Abnormal discharge present Take history, examine patient (external speculum and bimanual) and assess risk Lower abdominal tenderness or cervical motion tenderness Was risk assessment positive? Is discharge from the cervix? Vulval edema/curd like discharge Erythema excoriation present Treat for bacterial vaginosis and trichomoniasis Treat for chlamydia, gonorrhea, bacterial vaginosis and trichomoniasis Use flow chart for lower abdominal pain Educate Counsel Promote and provide condoms Offer VCT Educate Counsel Promote and provide condoms Offer VCT Treat for candida albicans No Yes Yes Yes No No No Yes Vaginal Discharge
Slide 68 - 68 Recommended Treatment for Vaginal Discharge Metronidazole 500mg PO BID for 7 days plus Clotrimazole vaginal tabs 200mg at bed time for 3 days Ciprofloxacin 500mg PO stat, or Spectinomycin 2gm IM stat plus Doxycycline 100mg PO BID for 7 days plus Metronidazole 500mg BID for 10 days Risk Assessment Negative for STI Risk Assessment Positive for STI
Slide 69 - 69 Prevention Counseling Nature of the infection Chlamydia is commonly asymptomatic in men & women Gonorrhea is usually asymptomatic in women Both easily transmitted during asymptomatic phase Both have serious adverse effects on women’s reproductive health if untreated CDC
Slide 70 - 70 Prevention Counseling (2) Transmission issues Effective treatment of chlamydia and/or gonorrhea may reduce HIV transmission Abstain from sexual intercourse until both partners are treated and for seven days after single dose therapy or until completion of a seven day regimen
Slide 71 - 71 Case Study: Redeit (cont.) Redeit leaves the OPD following evaluation for her vaginal discharge, but on the way home she loses the medication she was given. She does not return for additional medication out of embarrassment, but now two weeks later returns complaining of 3 days history of increasing pelvic pain and fever.
Slide 72 - 72 Case Study: Redeit (cont.) What is happening? What should be done now?
Slide 73 - 73 Lower Abdominal Pain Due to PID (Pelvic Inflammatory Disease) PID is ascending infection of the upper genital tract (uterus, tubes, etc) from the cervix and/or vagina Common etiologies: Sexually transmitted: Neisseria gonorrhea, Chlamydia trachomatis, Mycoplasma hominis Others (non-STI): streptococci, E. coli, etc Vaginal discharge is often present
Slide 74 - 74 Lower Abdominal Pain
Slide 75 - 75 Recommended Treatment for PID
Slide 76 - 76 Neonatal Conjunctivitis Infection of the eyes of the neonate as a result of genital infection of the mother, transmitted during birth Causes: Neisseria gonorrhea Chlamydia trachomatis Treatment: Spectinomycin 50mg/kg IM stat or ceftriaxone 125mg IM stat plus Erythromycin 50mg/kg PO in 4 divided doses for 10 days May lead to blindness if not treated properly
Slide 77 - 77 Neonatal Conjunctivitis
Slide 78 - 78 Case Study: Yiman Yiman is a 17 year-old boy who presents complaining of three days of increasing pain and swelling of his right scrotum. Symptoms began gradually, and he does not recall any trauma. He denies sexual activity.
Slide 79 - 79 Scrotal Swelling Common STI causes of scrotal swelling are similar to those of urethral discharge Neisseria gonorrhea Chlamydia trachomatis Exclude non-STI causes of scrotal swelling: TB Inguinal hernia Testicular torsion, etc
Slide 80 - 80 Scrotal Swelling Patient complains of scrotal swelling or pain Take history, examine, offer HIV test Scrotal swelling or pain present? History of trauma or testis elevated or rotated? or Diagnosis in doubt? Refer patient to hospital Signs of other STI present? Reassure patient, educate, counsel, provide condoms. Review if symptoms persist Treat according to appropriate flowchart Treat for chlamydia and gonorrhea. Review in 7 days Patient has improved? Complete treatment course, reinforce education and counseling Review if symptoms persist Yes Yes No Yes No No Yes No
Slide 81 - 81 Scrotal Swelling Recommended Therapy Ciprofloxacin 500mg PO stat, or Spectinomycin 2gm IM stat plus Doxycycline 100mg PO BID for 7 days, or Tetracycline 500mg BID for 7 days
Slide 82 - 82 Inguinal Bubo Swelling of inguinal lymph nodes as a result of STIs (or other causes) Common causes: Treponema pallidum (syphilis) Chlamydia trachomatis (LGV) Hemophylus ducreyi (chancroid) Calymatobacterium granulomatis (granuloma inguinale)
Slide 83 - 83 Inguinal Bubo Courtesy of CDC/ Susan Lindsley
Slide 84 - 84 Inguinal Bubo Patient complaining of inguinal swelling Take history and examine Inguinal/femoral bubo present? Ulcers present Treat for LGV, GI and chancroid Aspirate if fluctuant Educate on treatment compliance Counsel on risk reduction Promote and provide condoms Partner management Offer VCT if available Advise to return in 07 days Refer if no improvement Any other STI present Use appropriate flow chart Educate Counsel Offer VCT Promote and provide condoms Use genital ulcer flow chart No No Yes Yes No
Slide 85 - 85 Inguinal Bubo Recommended treatment: Ciprofloxacin 500mg PO BID for 14 days, and Erythromycin 500mg PO QID for 14 to 21 days
Slide 86 - 86 Key Points STIs are among the most common causes of illness in the world Emergence and spread of HIV infection and AIDS has major impact on the management and control of STIs STIs increase the acquisition and transmission of HIV HIV infection alters the clinical features and response to therapy of STIs
Slide 87 - 87 Key Points (2) The syndromic approach to STIs management is recommended by WHO Syndromic management is simple, rapid and inexpensive However, the syndromic approach leads to unnecessary over-treatment
Slide 88 - 88 Key Points (3) Partner notification and treatment are vital to interrupting STI spread Risk reduction education is key to preventing recurrence Every STD (or genital symptom) provides an occasion for patient education Cultural and interpersonal factors provide some of the greatest barriers to STD treatment and eradication