DEPARTMENT OF HEALTH Republic of South Africa

1. HIV/AIDS & STI Policy GuidelineClinical Management of Sexually Transmissible InfectionsDRAFT - 20 April 2001FLOWCHARTS DEPARTMENT OF HEALTH Republic of South Africa

2. Urethral discharge / Burning on micturition (BOM) in men (Confirmed cases - code URD) Patient complains of urethral dischargeor dysuria Take history and Examine. Milk urethra if necessary No • Educate and counsel • Promote and provide condoms • Offer HIV counselling and testing if both facilities are available • Review if symptoms persist Ulcer(s)present? No Discharge confirmed? Yes Yes Use appropriate flow chart • Treat for gonorrhoea and chlamydia • Educate • Counsel if needed • Promote and provide condoms • Offer HIV counselling and testing if both facilities are available • Partner management • Advise to return in 7 days if symptoms persist Figure 1

3. Persistent/Recurrent urethral discharge in men NB.: This flowchart assumes effective therapy for Gonorrhoea and Chlamydia to have been received and taken by the patient prior to this consultation Patient complains of persistent/recurrent urethral discharge or dysuria Take history and Examine. Milk urethra if necessary • Educate and counsel • Promote and provide condoms • Offer HIV counselling and testing if both facilities are available Ulcer(s)present? No Discharge confirmed? No Yes Yes Repeat urethral discharge treatment Yes Use appropriate flow chart Does history confirm re-infection or poor compliance? No • Treat for Trichomonas vaginalis • Educate • Counsel • Promote and provide condoms • Partner management • Return in 7days • Educate and counsel • Promote and provide condoms • Offer HIV counselling and testing if both facilities are available Improved? Yes No Refer Figure 2

4. Genital ulcers (Confirmed cases - code GUD) Patient complains of genital sore or ulcer Take history and examine • Educate and counsel • Promote and provide condoms • Offer HIV counselling and testing if both facilities are available Sore/Ulcer/Vesicle present? No Yes • Herpes simplex management • Educate • Counsel on risk reduction • Promote and provide condoms • Offer HIV counselling and testing if both facilities are available Vesicles or small ulcers with history of recurrent vesicles? Yes No • Treat for syphilis andchancroid • Educate • Counsel on risk reduction • Promote and provide condoms • Offer HIV counselling and testing if both facilities are available • Partner management • Advise to return in 7 days • Refer if necessary : Needs adaptation to local epidemiological situation Figure 3

5. Inguinal bubo (Confirmed cases without ulcer - code BUB) Patient complains of inguinal swelling Take history and Examine • Educate and counsel • Promote and provide condoms • Offer HIV counselling and testing • if both facilities are available Any other STI present? No Inguinal/femoral bubo(s)present? No Yes Yes Use appropriate flowchart Use genital ulcer flowchart Ulcer(s) present? Yes No • Treat for lymphogranuloma venereum and chancroid • If fluctuant aspirate through healthy skin • Educate on treatment compliance • Counsel on risk reduction • Promote and provide condoms • Partner management • Offer HIV counselling and testing if both facilities are available • Advise to return for review in 7 days, and continue treatment • If worse refer for further specialist opinion Figure 4

6. Scrotal swelling (Confirmed cases - code EPO) Patient complains of scrotal swelling/pain Take history and examine • Reassure patient and educate • Provide analgesics, if necessary • Promote and provide condoms • Offer HIV counselling and testing if both facilities are available No Swelling/pain confirmed? Yes • Treat for gonorrhoea and chlamydia • Educate • Counsel if needed • Promote and provide condoms • Partner management • Offer HIV counselling and testing if both facilities are available • Review in 7 days or earlier if necessary, if worse, refer Testis rotated or elevated, or history of trauma? No Yes Refer immediately for a surgical opinion Figure 5

7. Patient complains of vaginal discharge or vulval itching/burning Vaginal Discharge (Confirmed cases - code PVD) Take history, examine patient and assess risk • Educate • Counsel • Promote and provide condoms • Offer HIV counselling and testing if both facilities are available Abnormal discharge present? No Yes Use flowchart for Lower Abdominal Pain Lower abdominal tenderness? Yes No Treat for chlamydia trachomatis, gonococcal infection, bacterial vaginosis and trichomonas Was risk assessment positive? Yes No Treat for Candida Albicans Vulval oedema/curd like discharge Erythema, Excoriations present? Treat for bacterial vaginosis and trichomonas Yes • Educate • Counsel • Promote and provide condoms • Offer HIV counselling and testing if both facilities are available No : Needs adaptation to local social and behavioural epidemiological situation Figure 6

8. Vaginal Discharge (speculum & bimanual) Patient complains of vaginal discharge or vulval itching/burning Take history, examine patient (external, speculumand bimanual) and assess risk Educate Counsel Promote and provide condoms Offer HIV counselling and testing if both facilities are available No Abnormal discharge present? Yes Use flowchart for Lower Abdominal Pain Lower abdominal tenderness orcervical motion tenderness? Yes No Treat for chlamydia trachomatis, gonococcal infection, bacterial vaginosis and trichomonas Was risk assessment positive ORcervical mucopus detected? Yes No Treat for Candida Albicans Vulval oedema/curd like discharge Erythema, Excoriations present? Treat for bacterial vaginosis and trichomonas Yes No Educate Counsel Promote and provide condoms Offer HIV counselling and testing if both facilities are available : Needs adaptation to local epidemiological situation Figure 7

9. Patient complains of vaginal discharge or vulval itching/burning Vaginal Discharge (speculum & microscope) Take history, examine patient (external) and assess risk Was risk assessment positive? Treat for chlamydia trachomatis and gonococcal infection plus vaginal infection according to speculum and microscope examination findings Yes No Examine patient (speculum and bimanual) and perform wet mount/gram stain microscopy of vaginal specimen Motile trichomonads in wet mount pH>4.5 KOH negative Budding yeasts or pseudohyphae seen pH4.5 KOH negative Clue cells seen pH>4.5 KOH positive Mucus from cervix Cervical motion tenderness present? No findings Treat for Candida albicans Treat for Bacterial vaginosis Treat for chlamydia trachomatis and gonococcal infection Use flowchart for Lower Abdominal Pain Treat for trichomonas vaginalis Educate; Counsel; Promote and provide condoms; Partner management and, Offer HIV counselling and testing if both facilities are available, return if necessary Notes: 1. KOH Test: 1 drop 10% KOH to reveal the amine odour (fishy) 2. Wet mount: smear on slide with 1 drop of saline and view at 400X Needs adaptation to local epidemiological situation Figure 8

10. Lower abdominal pain (Confirmed cases - code PID) Patient complains of lower abdominal pain Take history (including gynaecological) and examine (abdominal and vaginal) Any of the following present? Missed/overdue period Recent delivery/abortion/miscarriageAbdominal guarding and/or rebound tenderness Vaginal bleeding Any other illness found? Is there cervical excitation tenderness or lower abdominal tenderness and vaginal discharge? No No Yes Yes Yes Manage appropriately • Manage for PID • Review in 3 days Refer patient for surgical or gynaecological opinion and assessment. Before referral set up an IV line and apply resuscitatory measures if necessary Patient has improved? No Refer patient Yes • Continue treatment until completed • Educate/counsel • Offer HIV counselling and testing if both facilities are available Figure 9

11. Neonatal conjunctivitis Neonate with eye discharge Take history and examine Bilateral or unilateral swollen eyelids with purulent discharge? • Reassure mother • Advise to return if necessary No Yes • Treat for gonorrhoea and chlamydiaTreat mother and partner(s) forgonorrhoea and chlamydia • Educate mother • Counsel mother • Advise to return in 3 days Refer Improved? No Yes Reassure mother Figure 10