Transcript Session 4

Sexually Transmitted
Infections
HAIVN
Harvard Medical School AIDS
Initiative in Vietnam
1
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
2
What is an STI?


Sexually Transmitted Infection
Infection spread from person to person
through sexual contact
3
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
4
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
5
Common STIs
6
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
7
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
8
Chlamydia and
Gonorrhea
9
Chlamydia: Chlamydia Trachomatis



Common
worldwide
75% of women
and 50% of men
have no symptoms
Diagnosis
Cervix with purulent discharge
• Urethral or cervical
swab: PCR or
ELISA
• Urine PCR
10
Chlamydia: Treatment
STI Treatment Guidelines, BVDL, HCMC, 2006
Recommended:
Doxycyline
Azithromycin
100 mg PO BID x 7 days
1 gram PO x 1 dose
Alternatives:
Erythromycin
Tetracycline
500 mg QID x 7 days
(safe for pregnant women)
500 mg QID x 7 days
Always treat for Gonorrhea as well!
11
Gonorrhea: Neisseria Gonorrhoeae
Epidemiology:
 Can cause urethritis, cervicitis, pharyngitis,
proctitis
Symptoms:
 Males usually have symptoms
of urethritis and purulent
discharge
 Females often have no
symptoms
12
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
13
Gonorrhea: Treatment
STI Treatment Guidelines, BVDL, HCMC, 2006
Treatment options:
Drug
Cefixime
Cefpodoxime
Ceftriaxone
Spectinomycin

Dosage
400 mg PO x 1 dose
400 mg PO x 1 dose
250 mg IM x 1 dose
2 gram IM x 1 dose
Flouroquinolones not effective for treatment due
to high levels of resistance
Always treat Chlamydia as well!
14
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
15
Pelvic Inflammatory Disease (PID) (2)

Examination, look for:
•
•
•
•
Fever
Tachycardia
Adnexal tenderness
Cervical motion tenderness
16
PID: Treatment
Drug
Dosage
Ceftriaxone
250mg IM x 1 dose
Doxycyline
100mg BID for 14 days
Metronidazole
400 mg BID for 14 days

Consider hospital admission for:
• Severe illness
• Pregnancy
• No improvement in 2-3 days
17
Epididymitis


Symptoms: pain and swelling of the
epididymus and scrotum
Diagnosis: based on symptoms and
clinical exam
Treatment:
Age
< 35 years old
Causes
Treatment
• STI (Chlamydia, treat for STI
Gonorrhea)
(ceftriaxone+doxycycline)
> 35 years old
• Klebsiella
and no risk for STI • E. Coli
• Pseudomonas
ofloxacin or levofloxacin x
10 days
18
1818
Vaginal Discharge
19
Vaginal Discharge


Diagnosis: wet-mount examination of
vaginal discharge with saline +/- KOH
Causes:
• Candida: thick, white discharge
• Bacterial Vaginosis: gardnerella vaginalis

Discomfort and malodorous discharge
• Trichomoniasis: Trichomonas vaginalis


Discomfort and discharge
Sexually transmitted - treat male partners
20
Vaginal Discharge: Treatment
Candida Infection:
Drug
Clotrimazole or
Miconazole
Clotrimazole
Fluconazole
Nystatin
Dosage
Topical x 3-7 days
500 mg intravaginally x 1 dose
150 mg oral x 1 dose
100,000 IU intravaginal daily x 14 days
Bacterial Vaginosis or Trichomonas :
Drug
Metronidazole
Dosage
500 mg 2x/day x 7 days
Metronidazole
2g x 1 dose (easier to take, but less effective
2121
than 7 day treatment)
Human Papilloma Virus
(HPV)
22
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
Population Risk, Management
HIV+ women
MSM
•
•
•
•
Increased risk for cervical cancer
Should receive a PAP smear regularly
Increased risk for anorectal warts and cancer
Regular screening is recommended by some
2323
experts
HPV (2)
24
HPV Treatment

Treatment (several weeks usually needed):
Treatment
Instructions
Cryotherapy- liquid nitrogen
every 1-2 weeks
Podophyllin
25% weekly (by doctor)
Podophyllotoxin (Condlyox)
BID x 3 days/week (by patient)
Electrocautery, surgery
25
A
B
Identify the STI
C
D
STIs That Cause Ulcers
27
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
28
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
29
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
3030
Chronic HSV Ulcers with HIV
3131
HSV: Diagnosis
Diagnostic Tests:
 PCR of lesions
 Serologic tests for HSV-1, HSV-2
 Viral culture
32
Genital HSV Treatment
Medication Primary Episode
Acyclovir
200 mg 5x/day x 7 days
Recurrent Episodes
200 mg 5x/day x 5 days
Acyclovir
400 mg 3x/day x 7 days
400 mg 3x/day x 5 days
Valaciclovir
1g 2x/day x 7days
1g 1x/day x 5 days
Famciclovir
250 mg 3x/day x 7 days
125 mg 2x/day x 5 days
Sources: STI Treatment Guidelines, BVDL, HCMC, 2006
WHO STI Guidelines, 2003
33
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
34
Syphilis
35
Syphilis: Treponema pallidum
Stage
Primary:
Symptoms
• painless ulcer or chancre at the site of
infection
Secondary:
• rash
• condyloma lata
• mucocutaneous lesions
• lymphadenopathy
Tertiary:
• cardiac
• eye
• nervous system abnormalities
Latent infection • Early (< 1 year)
(no
• Late (> 1 year)
3636
symptoms)
Primary Chancre of Syphilis
Syphilitic Rash
38
Secondary
Syphilis:
condyloma lata
39
Syphilitic
Rash
Syphilis is one of
the few skin
conditions that can
cause rash on the
palms and soles
40
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
41
Syphilis Diagnosis (2)
Only patients positive for both the screening test and
treponemal test need treatment
VDRL
RPR
TPA-abs
MHA-TP
–
+
–
–
–
+
+
+
Diagnosis
Treatment
No Syphilis
None
False-positive
None
Previously
treated &
cured
Positive for
Syphilis
None
Treat 42
42
Syphilis Treatment
Primary, secondary or early latent Syphilis (< 1 year)
Drug
Dosage
Benzathine penicillin 2.4 MU IM x 1 dose
Procaine penicillin
1.2 MU IM daily x 10 days
Late latent syphilis ( >1year) or unknown duration
Drug
Benzathine penicillin
Procaine penicillin
Doxycycline, tetracycline,
or erythromycin
Dosage
2.4 MU IM weekly x 3 doses
1.2 MU IM daily x 20 days
28 days
4343
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
44
Genital Ulcer:
Overall Treatment / Follow-Up
Visit
Management
First Visit
• Take history, confirm ulcer on physical
exam
• Do test for syphilis (VDRL or RPR)
• Treat for herpes
Second visit
after 7-10
days
• Evaluate clinical response to treatment
• Treat for syphilis, if positive
• If no response and syphilis negative,
refer to Dermatology-Venerology
45
specialist
A
B
Identify the STI
D
C
Questions:
How do STIs affect HIV?
How do they Interact?
47
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)
48
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
49
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
50
Key Points



Clinical manifestations of some STIs are
altered in the presence of HIV
STIs increase HIV transmission by 2-11
times
Treatment of STIs can decrease HIV
transmission
51
Thank you!
Questions?
52