Sexually Transmitted Infections

1. Sexually Transmitted Infections HAIVN Harvard Medical School AIDS Initiative in Vietnam

2. Learning Objectives By the end of this session, participants should be able to: • Identify the most common sexually transmitted infections (STIs) in Vietnam • Explain how to diagnose and treat these STIs • Describe the principles of syndromic management of STIs • Explain how STIs affect HIV infection

3. What is an STI? • Sexually Transmitted Infection • Infection spread from person to person through sexual contact

4. Key Principles About STIs (1) • STIs are an important public health concern • Complications of untreated STIs can be serious • E.g. cancer, infertility, increased HIV transmission • STIs can be diagnosed and treated based on the presenting symptoms or syndrome • However, many STIs can be asymptomatic; will only be detected by routine screening • When one STI is present, others are often present as well

5. Key Principles About STIs (2) • STIs are largely preventable • Prevention messages are easily given and reinforced, and include: • Education on safer sex and condom use • Provision of condoms (and lubricant) • Management of all sexual partners • Referral for HIV testing and counseling

6. Common STIs

7. What Are Some Common STIs? • Bacterial • Syphilis • Gonorrhea • Chlamydia • Protozoal • Trichomoniasis • Viral • Herpes • HIV • HPV/Genital Warts • Hepatitis B and C • Other • Pelvic Inflammatory Disease (PID) • Scabies

8. Common Symptoms of STIs by Gender • Females • Ulcers/sores • Vaginal discharge • Swelling/ growths/warts (groin/labia) • Burning on urination • Pain (low abdominal/back ache) • Males • Ulcers / sores • Discharge (urethral) • Swelling/growths –warts (groin / scrotum) • Pain / burning on urination

9. Chlamydia and Gonorrhea

10. Chlamydia: Chlamydia Trachomatis Cervix with purulent discharge • Common worldwide • 75% of women and 50% of men have no symptoms • Diagnosis • Urethral or cervical swab: PCR or ELISA • Urine PCR

11. Chlamydia: Treatment STI Treatment Guidelines, BVDL, HCMC, 2006 Recommended: Alternatives: Always treat for Gonorrhea as well!

12. Gonorrhea: NeisseriaGonorrhoeae Epidemiology: • Can cause urethritis, cervicitis, pharyngitis, proctitis Symptoms: • Males usually have symptoms of urethritis and purulent discharge • Females often have no symptoms

13. Gonorrhea: Diagnosis • Gram stained smears are 95-100% sensitive and 98% specific in male urethritis • Gram-negative intracellular diplococci • Culture –use special culture medium • Urine PCR

14. Gonorrhea: Treatment STI Treatment Guidelines, BVDL, HCMC, 2006 Treatment options: • Flouroquinolones not effective for treatment due to high levels of resistance Always treat Chlamydia as well!

15. Pelvic Inflammatory Disease (PID) (1) Infection of the endometrium and/or fallopian tubes Causes • N. Gonorrhoeae • C. trachomatis • Anaerobes • Mycoplasma Symptoms • Lower abdominal pain • Vaginal discharge • Bleeding • Fever • Dysuria • Dyspareunia • Nausea, vomiting

16. Pelvic Inflammatory Disease (PID) (2) • Examination, look for: • Fever • Tachycardia • Adnexal tenderness • Cervical motion tenderness

17. PID: Treatment • Consider hospital admission for: • Severe illness • Pregnancy • No improvement in 2-3 days

18. Epididymitis • Symptoms: pain and swelling of the epididymus and scrotum • Diagnosis: based on symptoms and clinical exam Treatment: 18

19. Vaginal Discharge

20. Vaginal Discharge • Diagnosis: wet-mount examination of vaginal discharge with saline +/- KOH • Causes: • Candida: thick, white discharge • Bacterial Vaginosis: gardnerellavaginalis • Discomfort and malodorous discharge • Trichomoniasis: Trichomonasvaginalis • Discomfort and discharge • Sexually transmitted - treat male partners

21. Vaginal Discharge: Treatment Candida Infection: Bacterial Vaginosis or Trichomonas :

22. Human Papilloma Virus (HPV)

23. HPV (1) There are many types of HPV • Some cause genital warts on the penis, anus, rectum, vagina, or cervix • Some cause cervical cancer and anal cancer

24. HPV (2)

25. HPV Treatment • Treatment (several weeks usually needed):

26. A B Identify the STI D C

27. STIs That Cause Ulcers

28. STIs that Cause Ulcers • The most common causes of genital ulcers in Vietnam are: • Herpes Simplex Virus (HSV) • Syphilis • Less common STIs that cause ulcers include: • Chancroid • Granuloma inguinale • Lymphogranuloma inguinale

29. Herpes Simplex Virus (HSV) • Common in many countries • 30-33% among female sex workers in S. Vietnam* • Lifelong and causes recurrent outbreaks • Two types of HSV: • HSV-1: usually causes oral infection • HSV-2: usually causes genital infection • Transmission increases during HSV outbreaks, but also occurs when there are no symptoms due to persistent viral shedding * O’Farrel, Int J STD AIDS, 2006

30. HSV: Symptoms • “Prodrome”: pain, tingling, numbness or itching at the site of the outbreak • Typical outbreaks are clusters of vesicles with pain, redness and swelling • HIV patients may have atypical symptoms: large, chronic ulcers

31. Chronic HSV Ulcers with HIV

32. HSV: Diagnosis Diagnostic Tests: • PCR of lesions • Serologic tests for HSV-1, HSV-2 • Viral culture

33. Genital HSV Treatment Sources: STI Treatment Guidelines, BVDL, HCMC, 2006 WHO STI Guidelines, 2003

34. Recurrent Episodes of HSV: Daily Suppressive Therapy • Daily suppressive therapy is for patients with multiple recurrences (> 5- 6/year) • Can reduce frequency of recurrences by >75% • No significant resistance • Dose: Acyclovir 400 mg 2x/day indefinitely

35. Syphilis

36. Syphilis: Treponema pallidum

37. Primary Chancre of Syphilis

38. Syphilitic Rash

39. Secondary Syphilis: condyloma lata

40. Syphilitic Rash Syphilis is one of the few skin conditions that can cause rash on the palms and soles

41. Syphilis Diagnosis (1) Nontreponemal “Screening” Tests: • VDRL or RPR • Initial screening test • Positive results should be confirmed Treponemal Serologic “Specific” Tests: • FTA-abs or MHA-TP • More expensive • Used to confirm a positive RPR or VDRL

42. Syphilis Diagnosis (2) Only patients positive for both the screening test and treponemal test need treatment

43. Syphilis Treatment Primary, secondary or early latent Syphilis (< 1 year) Late latent syphilis ( >1year) or unknown duration

44. Neurosyphilis Diagnosis: • Increased risk in PLHIV with CD4 < 350* • Evaluate any patient with syphilis and neurologic symptoms with CSF exam • CSF-VDRL (+) = neurosyphilis • May also have  WBC,  protein Treatment (Neurosyphilis or Ocular syphilis) • Penicillin G 4 MU IV q 4 h x 14 days * Source: JID, 2004

45. Genital Ulcer: Overall Treatment / Follow-Up

46. A B Identify the STI D C

47. Questions: How do STIs affect HIV? How do they Interact?

48. Effects of STIs on HIV Infection (1) • STIs increase transmission risk of HIV: • Ulcerative STIs (syphilis, chancroid, herpes) increase HIV risk 5 – 11 fold • Non-ulcerative STIs (gonorrhea, Chlamydia) increase risk 2 – 5 fold (perhaps higher for trichomonas)

49. Effects of STIs on HIV Infection (2) • Implications of the interaction: • Reduction in other STIs could result in reduction of HIV incidence • Effective STI prevention and control should be components of HIV prevention programs • All patients with STI should be offered counseling and testing for HIV

50. Syndromic Management • Treatment of STI symptoms based on the most likely etiologies in that location • Useful where diagnostic testing is not available or is too expensive • The WHO and Vietnam MOH have developed syndromic management guidelines for: • Urethral Discharge • Genital Ulcer • Vaginal Discharge • Lower abdominal pain in women