4.4 Management of Sexually Transmitted Infections in A PLHIV
4.4 Management of Sexually Transmitted Infections in A PLHIV
4.4 Management of Sexually Transmitted Infections in A PLHIV
Infections in PLHIV
Session Objectives
By the end of the session, the participants will be able to:
• Understand the Indian scenario on Sexually Transmitted Infections (STI) &
Reproductive Tract Infections (RTI)
• Understand interactions between STI/RTI and HIV
• Understand Symptoms and Signs of STI/RTI
• Enumerate Syndromic Management of STI/RTI
• Understand STI/RTI preventive measures
STI data from India
• Sexually Transmitted Infections/Reproductive Tract Infections (STI/RTI) are important public
health problems in India.
• WHO tracks four curable STI- Syphilis, Gonorrhea, Chlamydia and Trichomoniasis
• A community based STI/RTI prevalence study of 2002-03 conducted by ICMR for NACO
suggests :
• 5- 6% of the adults in India have one or more STI/RTI
• Which results into 30-35 million episodes of STI/RTI yearly among adults
• Data from the STI/RTI Control & Prevention Program suggests:
• significant decline of bacterial STI (syphilis, gonorrhea, chancroid)
• Increasing Viral STI (herpes, genital warts, hepatitis B)
• Significant burden of lower RTI (bacterial vaginosis and candidiasis)
• Some of the STI/RTI increase the risk of acquiring/transmitting HIV infection by 3 folds
Prevalence of STI: challenges in reporting of STI
Source: Program data collected from Designated STI/RTI clinics 2010 - 2016
Relationship Between STI/RTI And HIV
STIs
Impact of STI on HIV Viral Load
STD Infection Status HIV Genital Viral Load
No Gonorrhea 19%
Gonorrhea
Pre-treatment 44%
Post-treatment 21%
• Frequent urination
• Sore throat
Common Symptoms of STI/RTI in Women
Common Symptoms of STI/RTI in Women
STI/RTI Syndromes in Women
Symptoms Syndrome Common STIs/RTIs
• Frequency of urination
• Sore throat
Common Symptoms of STI in Men
STI/RTI Syndromes in Men
Symptoms Syndrome Common STIs/RTIs
• Illegal Abortions
• Asymptomatic clients can have STI/RTI and can transmit the same to their partners
• STI are transferred more from men to women as women are receptive and have a larger
surface area and longer contact period exposure
Transmission of STI/RTI: Women
Complication of STI/RTI
Untreated or partially treated STI/RTI can cause-
In Women
• Miscarriage
• Ectopic pregnancy
• Neonatal Syphilis
• Increased Risk of cervical cancer
In both Men and Women
• Infertility
• Increased risk of HIV transmission( 5-10 times)
• Late stages of Syphilis can effect heart and brain and sometimes cause death
In Men
• Epididymitis and Rectal Fistulas
Treating Sexually Transmitted Infections (STIs)
• 1160 Designated STI Clinic for general Population and for High Risk Group through TI
by 3400 Preferred Providers; “Suraksha Clinic”
• Provide quality standardised STI/RTI services at all levels; Colour coded kits (kit 1 to
kit 7) for Syndromic Management
• 8.64 million episodes treated in 2016-17
STI/RTI Episodes Management
89.2 90 86.4
79.6 80
70
• Over-treatment
Treatment: KIT 1
• Tab. Azithromycin 1gm , single dose
+
• Tab. Cefixime 400 mg , single dose
Vaginal Discharge Syndrome
• Vaginal discharge-cheesy white
• Assess :
• - quantity,
• - colour,
• - odor of discharge
• Itching around genitalia
Treatment: KIT 2
Tab. Secnidazole 1G , two tablets stat
+
Tab. Fluconazole 150 mg, single dose
Genital ulcer: Non Herpetic
Genital Ulcer; single or multiple;
painful or painless
Burning sensation in the genital area
Burning sensation in the genital area
Enlarged inguinal lymph nodes
Treatment: KIT 3
Inj. Benzathine Penicillin 2.4 MU given IM after sensitivity test
+
Tab. Azithromycin 1gm, single dose
Genital ulcer: Non Herpetic
Treatment: KIT 5
Tab. Acyclovir 400 mg tds X 7 days
Lower Abdominal Pain
Common symptoms/signs of Lower Abdominal Pain
• Fever
• Vaginal discharge
• Menstrual irregularities like heavy, irregular vaginal
bleeding
• Dysmenorrhoea, dyspareunia, dysuria, tenesmus
• Low backache
• Cervical motion tenderness
Treatment: KIT 6
Tab. Cefixime 400 mg single dose
+
Tab. Metronidazole 400 mg bid X 14 days
+
Tab. Doxycycline 100 mg bid X 14 days
Inguinal Bubo
Treatment: KIT-7
Tab Doxycycline 100 mg
bid X 21 days
+
Tab. Azithromycin 1gm
single dose
Anti-retroviral Therapy- most small warts disappear spontaneously as the immunity improves
Treatment of Large Warts:
• Chemical cauterization- 20% Podophyllin in compound tincture of benzoin
• Cryotherapy with liquid nitrogen, solid carbon dioxide or cryoprobe.
• Electrocautery
• Surgical excision
NACO Guidelines on Prevention, Management and Control of Reproductive Tract Infections and Sexually Transmitted Infections, July 2014
Key counselling messages to patients with HPV infection
• Genital HPV infection is very common.
• Many types of HPV are spread through genital contact, during vaginal and anal sexual
contact. HPV can also be spread by oral sexual contact.
• Usually HPV infection clears spontaneously, some infections do progress to genital warts,
pre-cancers, and cancers.
• The types of HPV that cause genital warts are different from the types that can cause
anogenital cancers.
• HPV vaccines are available, which offer protection against the HPV types that cause
cervical cancer and genital warts.
• Persons with genital warts should refrain from sexual activity until the warts are gone or
removed.
Molluscum contagiosum
Causative Organism: Pox virus. Facial molluscum lesions are one of the HIV defining
criteria.
Clinical features: Multiple, smooth, glistening, globular papules of varying size from a
pinhead to a split pea can appear anywhere on the body.
• Sexually transmitted lesions on or around genitals can be seen.
• Lesions are not painful except when secondary infection sets in.
• When the lesions are squeezed, a cheesy material comes out.
Diagnosis: Diagnosis is based on the above clinical features.
Treatment
• Individual lesions usually regress without treatment in 9-12 months.
• Needling followed by Chemical Cautery with 25% phenol solution or 30% trichloro-
aceticacid.
Ectoparasitic infections : Pediculosis pubis
Causative Organism: Lice - Phthirus pubis
Clinical features: There may be small red papules with a tiny central clot caused by lice
irritation.
• General or local urticaria with skin thickening may or may not be present.
• Eczema and impetigo may be present.
Treatment: Recommended regimen:
• Permethrin 1% crème rinse applied to affected areas and washed off after 10 minutes.
Special instructions:
• Retreatment is indicated after 7 days if lice are found or eggs observed at the hair-skin
junction.
• Clothing or bed linen that may have been contaminated by the client should be washed
and sun dried or dry cleaned.
Ectoparasitic infections : Scabies
Causative Organism: Mite - Sarcoptes scabiei.
Clinical features:
• Severe pruritis (itching) is experienced by the client, which becomes worse at night.
• Sexual transmission to the partner, other members may get infected through contact
with infected clothes, linen or towels).
Complications
• Eczematisation with or without secondary infection
• Urticaria
REF: NACO Guidelines on Prevention, Management and Control of Reproductive Tract Infections and Sexually
Transmitted Infections, July 2014
Scabies
Treatment
• Permethrin cream (5%) applied to all areas of the body from the neck down and washed
off after 8 - 14 hours.
• Benzyl benzoate 25% lotion, to be applied all over the body, below the neck, after a bath,
for two consecutive nights. Patient should bathe in the morning, and have a change of
clothing.
Special instructions
• Clothing or bed linen that have been used by the patient should be thoroughly washed
and dried well in the sun.
• Family members and Sexual partner must also be treated along the same lines at the
same time.
Norwegian scabies
• Crusted scabies, also called Norwegian scabies is an infestation characterized by thick
crusts of skin that contain large numbers of scabies mites and eggs.
• It is a severe form of scabies occurs in people who have a weakened immune system
• Treatment of crusted scabies can require oral medications along with multiple
applications of a scabicide cream
• Norwegian scabies is treated with topical permethrin cream and the
oral medication ivermectin
• Safety of Ivermectin in children weighing less than 15 kg and pregnant women not
established.
• Dose of Ivermectin: Oral drug 200 ug/kg single dose and repeat dose after 2 weeks
STI Control Objectives
• Interrupt the transmission of STIs
2. Compliance to treatment
6. Clinical follow-up
Prevention of STI/RTIs
Condom promotion program
Condom promotion is one of key prevention strategies of NACP IV
• Increase condom use as a barrier protection
• Increase the number of free condoms distributed through STI and STD clinics
*Bertran et al 2005
Why the foreskin is more prone for HIV infection?
• Contains more accessible HIV-1 target cells (CD4+ T cells, macrophages and Langerhans
cells)
• The Langerhans cells in the foreskin are closer to the epithelial surface, and are the first
to be infected by HIV
• Inner mucosal surface of the foreskin shows greater infectivity than that of cervical
tissue, which is a known primary site of HIV-1 acquisition in women
• increased risk of genital ulcer diseases
• Chronic, severe, resistant and atypical lesions are common presentations in HIV
• These conditions warrant that the ART Medical Officers, should examine Genital &
Ano-rectal areas especially in key populations
Thank You