Sexually Transmitted

Infections
Berhanu B, Clinical Pharmacist
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

2
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

3
STIs in Ethiopia

 No uniformity in reporting STI cases

 Only surveillance system is for HIV and syphilis
among pregnant women

4
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
5
Challenges to Prevention

 Difficult to change human behavior

 Co-infection with multiple STIs is common
 Not all STIs are treatable
 Many STIs are asymptomatic….more in females
Transmission can occur during asymptomatic
shedding.
Asymptomatic infection exists as a large “reservoir”
that perpetuates STI

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How Symptomatic are STIs?

Source: WHO HIV/AIDS/STI Initiative

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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

8
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

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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

10
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

11
STI Management
Syndromic Approach to STI Management

 Identification of clinical syndrome

 Giving treatment targeting all the locally known
pathogens which can cause the syndrome
laboratory testing not needed; treatment
provided immediately; effective in resource-
limited settings.
 Contrasts with “Etiologic Management.”
focused, specific therapy, avoiding the cost
and toxicity of unnecessary medications.
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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

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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

15
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
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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
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STI Syndromes and
Management
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

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Genital Ulcer Syndrome
Patient complains of genital ulcer

Take history & examine

Vesicles or recurrence
Yes
No No •Educate
Treat for HSV,
Ulcers and sores •Promote and
Treat for syphilis if indicated
provide
Yes condoms
•Offer VCT
•Educate and counsel
•Promote and provide condoms Treat for syphilis,
•Offer VCT chancroid and HSV
•Ask the patient to return in 7 days
No
No
Ulcers healed Ulcers improving Refer
Yes
Educate and counsel Yes
Promote and provide condoms
Offer VCT
Continue treatment for further 07 days
Partner management 20
Genital Ulcer Disease:
Differential Diagnosis
 Herpes simplex
 Syphilis
 Chancroid
 Lymphogranuloma venereum
 Granuloma inguinale
 Others

21
Secondary syphilis. Erythematous maculopapular
rash of secondary syphilis. Note presence on sole
of foot; syphilis is one of only a few skin disorders
to manifest on soles of feet or palms of hands.

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Courtesy of Peter Katsufrakis, MD
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

23
Herpes Viruses

 8 human herpesviruses (HHVs)

 α-herpes viruses include :
Herpes simplex virus (HSV)-1
Herpes simplex virus (HSV)-2
Varicella zoster virus
 β-herpes viruses include:
Epstein-Barr virus
Kaposi’s sarcoma-associated herpes virus (KSHV or
HHV-8)

24
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

25
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
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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

27
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%

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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

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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

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Differential Diagnosis

 Chlamydia
 Gonorrhea
 Mycoplasma hominis
 Ureaplasma urealyticum
 Hemophilus & Parahemophilus spp.
 Other bacteria

31
Urethral Discharge Syndrome
Patient complains
of urethral discharge
or dysuria

Take history
& do P/E; milk urethra
if necessary

•Educate and counsel

•Offer VCT
Discharge No Other STIs No •Review if symptoms
confirmed present? persist
•Promote and provide
yes condoms
Yes
•Treat for gonorrhea
and chlamydia
•Educate
•Counsel Use appropriate
•Promote and provide flow chart
condoms
•Offer VCT
•Partner management
•Advise to return in 7 days
if discharge persists 32
Recommended Treatment for Urethral
Discharge and Burning on Urination
 Ceftriaxone 250mg IM plus azithromycin 1gm po
stat, or
 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
33
 Patient complains of
persistent/ recurrent Persistent or Recurrent
urethral discharge or dysuria
Urethral Discharge in Men
Take history
and examine
•Educate/counsel
No Other STIs No •Promote and
Discharge confirmed provide condoms
present
• Offer VCT
Yes
Yes
Does history
confirm reinfection
Use appropriate
or poor compliance?
flow chart
No
Yes
Treat for trichomonas
vaginalis Repeat
•Educate/counsel urethral discharge
•Promote and provide condoms treatment
•Return in 7 days

•Educate/counsel
Improved Yes •Promote and provide condoms
No • Offer VCT
Refer
Genital Wart Treatments

 Internal  External
Bi- or tri- Podophyllin
chloroacetic acid Imiquimod
Cryotherapy Bi- or tri-
Cautery chloroacetic acid
Laser or other Cryotherapy
surgery Cautery
Laser or other
surgery
35
Vaginal Discharge

 Common causes:
Neisseria gonorrhea
Chlamydia trachomatis
Trichomonas vaginalis
Gardnerella vaginalis
Candida albicans

36
 Vaginal Discharge
Patient complains
of vaginal discharge or
vulval itching/ burning

Take history, examine patient

(external speculum and bimanual)
and assess risk

No Educate
Abnormal discharge present Counsel
Promote and provide condoms
Yes Offer VCT

Lower abdominal tenderness Yes

or cervical motion tenderness Use flow chart for lower abdominal pain
No

Was risk assessment positive? Yes

Is discharge from the cervix? Treat for chlamydia, gonorrhea,
bacterial vaginosis and trichomoniasis

No
Vulval edema/curd like discharge
Treat for bacterial vaginosis Yes
Erythema excoriation present
and trichomoniasis Treat for
No
candida albicans
Educate
Counsel
Promote and provide condoms 37
Offer VCT
Recommended Treatment for
Vaginal Discharge
Risk Assessment Positive for Risk Assessment Negative for
STI((i.e. multiple sexual STI: likely etiologies are
partners, recent unprotected Gardnerella and candida
sex, age < 25, etc)
Ciprofloxacin 500mg PO stat, or
Metronidazole 500mg PO BID
Spectinomycin 2gm IM stat for 7 days
plus plus
Doxycycline 100mg PO BID for Clotrimazole vaginal tabs 200mg
7 days at bed time for 3 days
plus
Metronidazole 500mg BID for 10
days
38
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

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CDC
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

40
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

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 Patient complains of
lower abdominal pain
Lower Abdominal Pain

Take history including gynecological

And examine (abdominal and vaginal)

Any of the following present Is there cervical excitation tenderness

•Missed overdue period Any other
Or lower abdominal tenderness
•Recent delivery/ abortion No illness found
No And vaginal discharge
•Miscarriage
•Abdominal guarding
Yes Yes
•And/or rebound tenderness
•Abdominal mass
•Abnormal vaginal bleeding Manage for PID
Manage
Review in three days
appropriately

Yes
No
Patient has improved Refer patient
Refer the patient for surgical or
gynecological opinion Yes
and assessment
Continue treatment until completed
•Educate and counsel
Before referral set up
•Offer VCT
an IV line and resuscitate
•Promote and provide condom
if required 42
•Ask patient to return if necessary
 Recommended Treatment for PID
Out patient Inpatient
Ciprofloxacin 500mg PO bid Ceftriaxone 250mg IV BID,
for 7 days, OR OR
Spectinomycin 2gm IM stat Spectinomycin 2gm IM BID
plus plus
Doxycycline 100mg BID for 14 Doxycycline 100mg BID for 14
days days
plus plus
Metronidazole 500mg BID for Metronidazole 500mg BID for
14 days 14 days, OR Chloramphenicol
500mg IV QID
43
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

44
 Neonate presents with eye discharge Neonatal Conjunctivitis
Take history and examine child

No No Reassure mother,
Purulent conjunctivitis present? Signs of other illness
educate parents
present?
Review if symptoms persist
Yes
Yes
Treat baby for gonococcal and
chlamydial opthalmia Treat appropriately
AND
Treat mother and partner for gonorrhoea
and chlamydia
Educate and counsel
Review baby in 7 days or sooner
if symptoms worsen

Review in
7 days
Yes Complete treatment course,
Eye infection cleared? reinforce education and counseling
Review if necessary
No

Refer for specialist opinion

and management 45
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

46
 Patient complains of
scrotal swelling or pain
Scrotal Swelling

Take history, examine,

offer HIV test

No No Reassure patient, educate,

Scrotal swelling or Signs of other counsel, provide condoms.
pain present? STI present? Review if symptoms persist
Yes
Yes
Treat according to
History of trauma or testis appropriate flowchart
elevated or rotated?
or
Diagnosis in doubt? No Treat for chlamydia
and gonorrhea.
Yes Review in 7 days
No
Refer patient to Yes
hospital
Patient has improved? Complete treatment course,
reinforce education and counseling
Review if symptoms persist
47
Scrotal Swelling
Recommended Therapy
 Ceftriaxone 250mg IM plus azithromycin 1gm po
stat, or
 Ciprofloxacin 500mg PO stat,
or
 Spectinomycin 2gm IM stat
plus
 Doxycycline 100mg PO BID for 7 days, or
 Tetracycline 500mg BID for 7 days

48
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)

49
Patient complaining of
inguinal swelling
Inguinal Bubo
Take history
and examine

•Educate
Inguinal/femoral No No •Counsel
bubo present? Any other STI present •Offer VCT
•Promote and provide condoms
Yes

Use appropriate flow chart

Ulcers Yes
present Use genital ulcer flow chart

No
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
50
Inguinal Bubo

 Recommended treatment:
Ciprofloxacin 500mg PO BID for 14 days, and
Erythromycin 500mg PO QID for 14 to 21 days

51
End!!

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